Current through Register 1531, September 27, 2024
(1)
Rate Calculation. The Division will calculate the rate
by determining total reimbursable rate year costs, subtracting client resources
and, if necessary, dividing by projected service units.
(a) For programs having at least one year of
historical cost, the Division will determine total reimbursable rate year costs
by:
1. Adjusting the most recent available
annual cost data using the principles set forth in 114. 5 CMR 4.04
2. Increasing adjusted historical costs,
exclusive of fixed costs as defined in 114. 5 CMR 4.02, by a cost adjustment
factor to project them to the rate year. The cost adjustment factor shall
reflect appropriate projections of inflation indices and shall to the extent
practicable be consistent with cost adjustment factors used in other Division
regulations for similar providers. In appropriate circumstances the cost
adjustment factor may be zero.
3.
Adjusting for the reasonable costs negotiated by the provider and purchasing
governmental unit which relate to the following:
a. Increases in operating costs due to
compliance with changes in the laws or regulations concerning licensing or
safety;
b. Changes in operating
costs due to negotiated changes in the program; or
c. Unforeseen or unusual increases in
operating costs which are beyond the control of the provider and which are not
contemplated in the cost adjustment factor.
(b) For programs not having at least one year
of historical cost, the Division will determine total reimbursable rate year
costs by adjusting budgeted costs using the principles set forth in 114. 5 CMR
4.04 and including negotiated costs as allowed for established programs
pursuant to 114. 5 CMR 4.05(1)(a)3.
(2)
Rate Calculation for
Out-of-State Providers. The Division will calculate the rate based
upon, at its discretion, the provisions of 114. 5 CMR 4.05, the out-of-state
provider's current charge to the general public, or the rate established by an
out-of-state governmental agency.
(3)
Requirements for Consultant
Services.
(a)
Requirements of Rate Approval. Any governmental unit
purchasing consultant services from a provider under 114. 5 CMR 4.00 shall
file, or cause to be filed, a copy of the agreement for the provision of
consultant services with the Division. In the absence of a written agreement,
the governmental unit shall provide a description of the services being
purchased, the name of the provider of such services, and the rate of payment
which the governmental unit proposes to pay such provider. In the absence of a
specific provider, the governmental unit shall provide a description of the
services and the rate which it proposes to pay such provider.
(b)
Standard of
Review. If the Division determines that the consultant services
are subject to its rate determination or approval authority but are not subject
to rate determination under any other chapter of 114 CMR, it shall review the
proposed rate of payment under 114. 5 CMR 4.00. If the proposed rate of payment
is reasonable for the consultant services provided, the rate shall be approved
by the Division, in accordance with M.G.L. c. 118G. In reviewing the
reasonableness of the proposed rate, the Division may refer to the prudent
buyer concept, rates determined under the chapters of 114 CMR, rates determined
under
801 CMR
4.07 and the payment Title Code Manual issued
by the Division of Personnel Administration.
(4)
Rate Calculation where
Information Is Insufficient. If there is insufficient information
to apply the provisions of 114. 5 CMR 4.05(1)(a) or (b) or 114.5 CMR 4.05(2),
the Division in its discretion and with the consent of the provider and
principal purchasing governmental unit, may certify a rate determined in any
manner consistent with the principles set forth in 114. 5 CMR 4.00 and the
Division's authority under M.G.L. c. 118G.
(5)
Federally Determined
Rate. The Division at its discretion may certify a rate equal to a
rate established by an agency of the Federal Government, including, but not
limited to, the Health Care Finance Administration (HCFA) or Indian Health
Services.
(6)
Rate
Limitations.
(a) No rate
approved under 114. 5 CMR 4.00 shall exceed a program's established
charge.
(b) Except in the case of
cost reimbursement, no purchasing governmental unit may pay less than the rate
established by the Division.
(7)
Reimbursement as Full
Payment. Each provider shall, as a condition of acceptance of
payment made by one or more purchasing governmental units for care provided,
accept the rate established by the Division as full payment and discharge of
all obligations for the care so provided. There shall be no duplication or
supplementation of payment from sources other than those expressly recognized
or anticipated in the computation of the rate. Any client resources or third
party payments on behalf of a publicly aided client, not expressly recognized
or anticipated in the computation of the rate, shall reduce the obligation of
the appropriate purchasing governmental unit for care rendered to that
client.
